PEPTIC ULCERATION

Introduction
Peptic ulceration is a term which includes both gastric and duodenal ulceration.
A peptic ulcer consists of a break in the superficial epithelial cells penetrating down
to the muscularis mucosa of either the stomach or the duodenum. It is associated
with a fibrous base and an increase in inflammatory cells.
Population
Risk factors

Presentation

Examination (It is usually

normal in the
uncomplicated cases)
Investigation
Complications

Gastric ulcer
Duodenal ulcer
Middle-aged/elderly male
Young-middle-aged male
H.pylori (70-90%)
H.pylori (>90%)
NSAID use (increase risk
NSAID use
by 3-4 times)
Gastric hyperacidity
Delayed gastric emptying
Rapid gastric emptying
Dyspepsia
Dyspepsia
Epigastric pain worsened
Epigastric pain typically
by food and helped by
relieved by food and
antacids or lying flat
worse at night
weight loss
overweight
*Anorexia and weight loss
May be epigastric/left
May be epigastric
upper quadrant
tenderness
tenderness
Same as dyspepsia (Endoscopy / H.pylori test)*
Haemorrhage
Perforated peptic ulcer
Pyloric stenosis in adults (duodenal stenosis secondary
to scarring from a chronic DU)

Helicobacter pylori infection

H.pylori is a slow-growing spiral Gram-negative flagellate urease-producing
bacterium. It colonizes the mucous layer in the gastric antrum, but is also found in
the duodenum in areas of gastric metaplasia. It adheres specifically to gastric
epithelial cells and being protected from gastric acid by the juxtamucosal mucous
layer which traps bicarbonate secreted by antral cells, and ammonia produced by
bacterial urease.
Antral cells
H. pylori

Bicarbonate ions
Urease (Urea

Results of infection:

NH3 + CO2)

Adapted to the
environment which is
highly acidity

Antral gastritis
Peptic ulcers
Gastric cancer

Investigation
Endoscopy for those who meet the referral criteria as below:
(!Alarm
symptoms)
- Chronic gastrointestinal bleeding
- Progressive unintentional weight loss
- Progressive difficulty swallowing
- Persistent vomiting
- IDA
- Epigastric mass
- Suspicious barium meal
- Age > 55y and recent-onset and persistent, unexplained dyspepsia
- Previous gastric ulcer or surgery
- Continuing need for NSAID treatment
- Increase risk of gastric cancer
- Anxiety about cancer
[STOP NSAIDS and PPI/H2 receptor antagonists for 2wks prior to the procedure!!]

H.pylori test
1. Non-invasive

Serology (IgG antibodies)

Urea breath test
Faecal antigen test

[STOP PPI for 2 wks prior to breath test {stop taking antibiotics 4 wks prior
to the test} and stool antigen test!!]
2. Invasive:
(endoscopy)

Biopsy urease test

Histology
Culture

Management
Eradicate H.pylori if present (clear 80-85% of H.pylori infections)
PMC500 (1 wk)

PAC250 (1 wk)

Full dose PPI (eg. Omeprazole 20mg

BD)
Amoxicillin 1g BD
Clarithromycin 500mg BD
Full dose PPI (eg. Omeprazole 20mg
BD)
Metronidazole 400mg BD
Clarithromycin 250mg BD

Resistant infections

Bismuth chelate 120mg tds

Metronidazole 400mg tds 2 wks
Tetracycline 500mg qds
PPI 20-40mg BD

*Check eradication with repeat endoscopy (gastric ulcer) or urea breath test
(duodenal ulcer)
If negative H.pylori
Full dose PPI (eg. Omeprazole 20mg OD) for 1-2 mths
*If gastric ulcer, re-endoscope to check the healing of ulcer
Stop NSAIDs
Lifestyle advice
- Healthy eating
- Lose weight
- Smoking cessation
- Avoid precipitating factors (alcohol, coffee, chocolate, fatty foods)
- Use of antacids/alginates